Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation

Abstract

At the present time the preferred technique for biliary reconstruction in adult living donor liver transplantation (ALDLT) is the Roux-en-Y hepaticojejunostomy (HJ). Patients undergoing HJ are not drained through the normal physiologic route and may suffer from repeated bouts of ascending cholangitis. The inability to evaluate and treat biliary strictures and leaks by endoscopic retrograde cholangiography (ERCP) may complicate the postoperative management of patients undergoing HJ. Modifications aimed at preserving the blood supply to both the donor and recipient bile ducts may allow a direct duct-to-duct (D-D) biliary reconstruction in selected patients, and aid in visualization of the biliary tree and eliminate complications related to reflux cholangitis. Adult living donor liver transplantation, using a right lobe, is emerging as an effective treatment option for selected patients awaiting liver transplantation. Though many variations in technique exist between centers performing this procedure, most surgeons use an HJ as the preferred method for biliary-enteric reconstruction. The rationale for use of the HJ for biliary reconstruction in segmental liver grafts, such as those used in pediatric recipients, derives from the small size of the recipient bile duct and inadequate length of the donor bile duct. In addition, the underlying liver disease (eg, biliary atresia) often mandates an HJ. Finally, there are concerns relating to the vascular integrity of the anastomosis, especially with left-sided grafts, because important blood vessels may arise to the left hepatic duct from segment IV vessels. Although HJ remains the standard of care in pediatric segmental grafts, the use of HJ in adult segmental grafts, such as those used in ALDLT, would not appear to be mandatory for several reasons. First, most adult liver diseases do not prohibit a choledocho-choledochostomy. Second, the size of the adult bile duct is not a restricting factor; and finally, the vascular integrity of the anastomosis can be preserved by careful attention to surgical technique and a greater understanding of the vascular supply to the bile ducts. The fact that a D-D anastomosis is the preferred method for biliary reconstruction in cadaveric liver transplantation relates to its preservation of the normal physiologic sphincter mechanism and consequent reduction in the incidence of reflux cholangitis. In addition, it reduces operative time, allows easier access for radiologic evaluation of the biliary tract by ERCP, and avoids creation of an enteric anastomosis that may leak, cause infection, or act as a site for internal hernias. This article describes a modification of our standard procedure for ALDLT, which allows a well-vascularized and tension-free D-D anastomosis.